Provider Demographics
NPI:1689749749
Name:ST. MARY'S MEDICAL CENTER OF CAMPBELL COUNTY, INC.
Entity type:Organization
Organization Name:ST. MARY'S MEDICAL CENTER OF CAMPBELL COUNTY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ANGEL
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:JIMENEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:865-545-7558
Mailing Address - Street 1:923 E CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:LA FOLLETTE
Mailing Address - State:TN
Mailing Address - Zip Code:37766-2768
Mailing Address - Country:US
Mailing Address - Phone:423-907-1200
Mailing Address - Fax:423-907-1164
Practice Address - Street 1:200 TORREY RD
Practice Address - Street 2:
Practice Address - City:LA FOLLETTE
Practice Address - State:TN
Practice Address - Zip Code:37766-2728
Practice Address - Country:US
Practice Address - Phone:423-907-1379
Practice Address - Fax:423-907-1189
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MERCY HEALTH PARTNERS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-22
Last Update Date:2010-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BN1400XSuppliersDurable Medical Equipment & Medical SuppliesNursing Facility Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1452065Medicaid
TN1452065Medicaid